Prevention and Cessation Education in US Medical Schools

Harvard Tobacco Control

Working Group

March 17, 2004

NCI R25-CA9-1958-02

At the end of this five-year grant, we anticipate that tobacco education modules will be successfully incorporated into a number of US medical schools and graduating students at these schools will be able to skillfully perform tobacco prevention and cessation counseling for children, adolescents, and adults.

PACE (August 1, 2002 – July 31st, 2007)

PACE Study Sites and Number of Enrolled Students

Dartmouth Medical School – (286)

University of Kentucky – (368)

University of Rochester – (391)

University of South Florida – (397)

University of Massachusetts Medical School – (419)

Case Western Reserve University – (566)

PACE Study Sites and Number of Enrolled Students (cont.)

University of Iowa – (591)

UCLA – (598)

Boston University – (623)

University of Alabama at Birmingham (UAB) – (643)

Loma Linda University – (653)

Harvard University – (712)

Rationale for selection of sites: As our long-term objective is inclusion of tobacco control curriculum in multiple US medical schools, we have selected a representative sample of these schools. We used the following criteria for choosing sites:

a.) Public and private schools;b.) The major geographic sites in the United States;c.) Inner city and rural areas;d.) Schools with varying amounts of tobacco education (range of no current content to multiple modules);e.) Internet access to students for survey completion.

Evolution of Current NCI R-25 Award

a.) Missed opportunities-"specific curriculum devoted to smoking cessation and prevention must become a mandatory component of undergraduate education in every US school"-JAMA 1994

b.) Work of UMass teamc.) Linda Ferry article-JAMA 1999d.) BU R25-Preventive Medicine 2002e.) Collaborations with American Association of

Cancer Education

Percent of Current Smokers Ever Receiving Advice to Quit from Physicians and Dentists

26%

51%56% 56%

19%

60%

21%

63%

25%

0%10%20%

30%40%

50%60%

70%80%90%

100%

1974 1986 1991 1993 1996 1999

PhysicianDentist

Source: NHIS 1974, 1986, 1991; CPS 1993, 1996, 1999.

Physicians’ Counseling Behavior*

74%67%

35%

8%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ask

> 8

0%of

pat

ient

sab

out

smok

ing

stat

us

Adv

ise

>80

% o

fsm

okin

gpa

tient

s to

quit

Ass

ist >

80%

of

smok

ing

patie

nts

Arra

nge

follo

w-u

pfo

r > 8

0%of

sm

okin

gpa

tient

s

*A representative sample of 246 community-based Rhode Island primary care physicians

Source: Goldstein MG, DePue JD, Monroe AD, et al. A population-based survey of physician smoking cessation counseling practices. Preventive Medicine. 1998;27:720-729.

Percent of Pediatricians Reporting Giving Advice to Parents of Patients, CA (1997-8)

62%

5%

13%

73%

18%

56%

0%

20%

40%

60%

80%

100%A

ski

ng a

bout

sm

oki

ng s

tatu

s

Recom

mendin

gsettin

g a

quit

date

Pre

scribin

gN

RT

Schedulin

g a

follo

w-u

p v

isit

or

tele

phone c

all

Ask

pare

nts

ifth

ey

sm

oke

insid

e their

house

Aski

ng p

are

nts

about sm

oki

ng

in fro

nt of th

eir

child

outs

ide

the h

om

e

CESSATION ADVICE ETS ADVICE

Source: Perez-Stable EJ, Juarez-Reyes M, Kaplan CP, Fuentes-Afflick E, Gildengorin V, Millstein SG. Counseling smoking parents of young children: comparison of pediatricians and family physicians. Arch Pediatr Adolesc Med. 2001;155:25-31.

National Cancer Institute panel (1992)

a.) Specific curriculum devoted to smoking cessation

and prevention must become a mandatory

component of undergraduate medical education;

b.) An assessment of tobacco curricula at medical

schools is necessary;

c.) Certain core materials can serve as key

components of different tobacco curricula;

National Cancer Institute panel (1992) (cont.)

d.) The effectiveness of a smoking cessation and prevention

curriculum must be evaluated

e.) Questions on this topic should be included as part of the

USMLE steps 1,2,3;

f.) The AMA and the Association of American Medical Colleges

(AAMC) and other organizations are important vehicles for

promoting discussion and action;

A National Action Plan for Tobacco Cessation (2004)

‘clinicians feel inadequately prepared to intervene with patients who smoke and appraisals of medical school curricula reveal little training in tobacco intervention strategies’

 

Subcommittee recommended that ‘USDHH provide grants to medical and other health professional schools to develop, implement, and evaluate curriculum for treatment of tobacco dependence’ ‘Licensure and certification exams assess knowledge of tobacco dependence’ ‘Ensure that competency in tobacco dependence interventions is a core graduation requirement for all new physicians’

(AJPH February 2004)

Year Course Topic # Hours

 

1 Essentials of Public Health Cancer prevention and detection 2

1 Essentials of Public Health Case-control studies on tobacco and lung cancer 1

1 Introduction to Clinical Medicine Introduction to substance abuse – Tobacco cessation 1

2 Biology of Disease-Cardiology Discussion of tobacco effects

0.5

2 Biology of Disease-Pulmonary Diseases Discussion of tobacco effects

0.5

2 Introduction to Clinical Medicine Cancer skills laboratory 2

3 Pediatric Orientation Role of pediatrician in smoking prevention 1

3 Introduction to Ambulatory Medicine Cancer communication skills laboratory 2

4 Home Medical Service Cancer detection in the elderly 1

 

Tobacco Curriculum Boston University Medical School (BUSM) 2003

Self-Rated Skills Among BUSM IV by Chronological Year

33.13.23.33.43.53.63.73.83.9

44.14.24.34.44.5

1996 1997 1998 1999

Mean scores with responses ranging from 1(very unskilled) to 5 (very skilled)

SmokingpreventioncounselingSmokingcessationcounselingSun protectioncounseling

Skin cancerexamination

Clinical breastexamination

Obtaining smearsfor Pap test

0%10%

20%30%

40%50%60%

70%80%

90%100%

Sm

ok

ing

As

se

ss

me

nt

Inju

ryP

rev

en

tio

n

Sm

ok

ing

As

se

ss

me

nt

Inju

ryP

rev

en

tio

n

Sm

ok

ing

As

se

ss

me

nt

Inju

ryP

rev

en

tio

n

Sm

ok

ing

As

se

ss

me

nt

Inju

ryP

rev

en

tio

n

Preceptor madeexpectations clear

Observe preceptor talkwith family

Preceptor observe youtalking with family

Preceptor gave youfeedback

Yes

No

Proportion of BUSM III (2001-02) completing assessments as a function of

preceptor reinforcement

Smoking Prevention Activities Conducted by BUSM III

(average response per six weeks)

0

10

20

30

40

50

60

70

Discourageparents from

smoking in thehouse

Initiatediscussions withchildren about

smoking

Discuss nicotinereplacement

therapy (NRT)with parents

Ask parent if theytalked with childabout smoking

Offer tips forparents to

counsel childrenabout smoking

PACE Design (2003-2007)

NA = Needs Assessment

SS = Student Surveys (2nd + 4th year students)

* Course development consists of the creation of three separate modules

^ Module Intervention I is the stage in which each school initiates the one course that the PI took part in developing

+ Complete module intervention is the stage when each of the 12 schools initiates all modules that were developed

# The national dissemination stage is when the modules are made available to all medical schools in the United States

2003 2004 2005 2006 2007

Education Course

Development *

Module Intervention

I^

Complete Module

Intervention +

National dissemination

#

Evaluation NA SS Course Evaluation

SS/NA

PACE Timetable

Aim 1/Year 1- Assess current curriculum and organize and convene a national

conference

Aim 2/Year 2- Develop new curriculum, plans for integration, and conduct

faculty training

Aim 3/Year 3- Conduct trial implementation of new curriculum

Aim 3/Year 4- Share ‘best content’ across all 12 schools

Aim 4/Years 1-4 Conduct a comprehensive process and

impact evaluation

Aim 5/Year 5- Disseminate Resource Guides/Tool Kits to other

medical schools

Assessment of Current Curriculum

What is currently being taught?- Can get to minutes but not quality of teaching

Defining what needs to be taught? - Educational visioning

Offering means to address the deficit

- Course development, evaluation of sites of inclusion

Courses and Tobacco Content (12 schools)

Courses with Tobacco

41 (range=0-7)

mode=2,5 mean=3

39 (range=1-10)

mode=3 mean=3

26 (range=1-7)

mode=2 mean=3

Courses

112 (range =6-11)

mode=9 mean=9

92 (range =4-17)

mode=6,7 mean=8

92 (range =4-10)

mode=5 mean=6

YEAR 1

YEAR 2

YEAR 3

Number of Tobacco Hours by School (n=12)

0

1

2

3

4

5

6

# of Schools

< 5 hours 6-9 hours 10-15 hours 27 hours

Hours

Clerkships

Heavy Hitters:

Family MedicineInternal Medicine

Soft Spots:PediatricsOB GYN

Lack of Faculty Training for Tobacco Prevention and Cessation (“NO” Responses)

Among 12 US Medical Schools

0

2

4

6

8

10

12

Tobacco CME's Prevention/CessationGuidelnes

Prevention CourseWorkshop

Mentor/MasterTeaching

InstructionalDevelopment Seminar

PharmacologicTherapy

Uncovered Impediments to Reform

 Time overload-stealth approach

- Advantage-cuts across so many disciplines

Lack of any organized tobacco infrastructure Far more didactics than skills

Aim 2-Development of New Curriculum Modules, Plans for Integration, and Faculty Training (Year 2)

a) Formulate graduating competencies for tobacco control education and related goals and objectives;

b) Construct a formally evaluated series of educational modules for teaching in all medical school years, both in preclinical and clinical years.

c) Develop strategies to integrate the educational modules into existing courses specific for each school;

Why integrate tobacco control curriculum?

Tobacco control should be part of basic skills of ALL medical students “ what every student should know”

Core courses are venues for basic skills

Year 2 Tasks Resulting from Initial PACE Meeting

Major Domains Tasks

Adult cessation

Pediatric Prevention

Public Health Approaches

Preceptor education

Clerkship orientations and in-services

Integrate tobacco into community

health programs

Other – OB/GYN

Study Design/Timeline

Pediatrics Orientation

(4 Schools)

Preceptor Orientation

(4 Schools)

Community Electives

(4 Schools)

2004-5

Pilot Year

2005-6

PACE School Dissemination

BU CWRU Dartmouth Harvard Loma Linda UAB

U.KentuckyUCLA U.Iowa UMass U.Rochester USF

2006-7

U.S. Medical Schools

Dissemination

All U.S. Medical Schools

Graduating competencies are

organized according to:

a.) Adult cessation and prevention competencies;

b.) Pediatric prevention and cessation competencies;

c.) Public health advocacy/population science competencies;

d.) Support systems in clinic/medical setting competencies; and

e.) Professional development/global competencies

All presentations will be tailored and available as:

Seminar presentationsAudioCDWritten copies of print-outsWith teacher manualsHand-outs for students to give to patients

The Difference Between a Curriculum and a Pile of Stuff

Transferability: Contains tools and resources so others can use it

Ease of Use: Materials are well organized and complete Format: Materials conform to a common format. Synergy: Modules fit together coherently Coverage: Adequate coverage of a competency area

PRECEPTORSHIP MODULE

Students must practice what they have learned in the classroom

Students model what they see in clinical settings

Preceptors have an important role as teachers and mentors

Will be encouraged to promote feedback

Community Tobacco Electives

Teaching and training: First year and fourth

year students

Tobacco Advocacy: working with national organizations on policy and legislation

On-line training in tobacco prevention and

cessation

Exploratory:

OB GYNNational Board of Medical Examiners Step IIbUS Student OrganizationsInternational medical students